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This is a personal web site, reflecting the opinions of its author. It is not a production of my employer, and it is unaffiliated with ANY hospital, medical center, medical practice or other physicians. Statements on this site do not represent the views or policies of anyone other than myself. The information on this site is provided for discussion purposes only, and are not medical recommendations. I offer no guarentee as to the accuracy of anything stated and the information here is at times, highly speculative and does not constitute advice to/not to diagnose or treat. Any personal medical issues the reader may have should be referred immediately to the reader's private physician and under no circumstances should anyone delay, change, or alter any medical treatment or planned treatment or diagnosis based on anything read on this site. Under no circumstances does any herein contained information represent a medical recommendation.

I'm getting tired of hearing what neurologists have to say about Terri Schiavo's CT of the brain. Real Tired. The Florida Sun Sentinel had a gang of neurologists analyze one of Terri's CT's of the brain. Here's what they said:

About 70 percent to 90 percent of Schiavo's upper brain is gone, and there's also damage to her lower brain that controls instinctive functions such as breathing and swallowing, said three Florida neurologists who viewed 12 of her CT "computed tomography" X-ray scans Tuesday and Wednesday.

"This is as severe brain damage as I've ever seen," said Dr. Leon Prockop, a professor and former chairman of neurology at the University of South Florida College of Medicine in Tampa, upon viewing the scans.

Then there's the infamous Dr. Ronald Cranford, who has the double-whammy credentials of neurologist AND bioethicist (have you had enough of bioethicists for a while? Why is it they all have the same opinion and they all start out their spiels by saying "this is a tragic case for everyone involved...") who also defined Terri's CT of the brain as being as bad as he's seen.

So What Have You Seen?

I've watched a steady stream of neurologists, bioethicists, and neurologist/bioethicists from Columbia, Cornell, and NYU interviewed all week on Fox and CNN and MSNBC. They all said about the same thing, that Terri's CT scan was "the worst they'd ever seen"or "as bad as they've ever seen."

Here's the problem with these experts: THEY DON'T INTERPRET CT SCANS OF THE BRAIN. RADIOLOGISTS DO.

*Oh*

You see, a neurologist will look at the CT of the brain of one of his patients, but this is entirely different from interpreting CT's of the brain de novo, for a living, every day, without knowing the diagnosis and most times without a good history. In addition, whereas I heard Dr. Crandon say he's "seen" a thousand brain CT's... well I've interpreted over 10,000 brain CT's. There's a big difference.

When I look at a CT of the brain every case is a new mystery about a patient Idon't know. I must look at the images, come to a conclusion, dictate my findings and report a conclusion. This becomes a part of the official legal record for which I am liable. I bill Medicare for a CT interpretation and am paid for this service.

Neurologists do not do this. They don't go on the record, alone, in written legal documents stating their impressions about CT's of the brain. The neurologist doesn't get sued for making a mistake on an opinion of a CT of the brain THE RADIOLOGIST DOES.

A neurologist has no where near this type of practical experience. And their cases are skewed according to where they practice and what their specialty is. Now, some of my best friends and some of the smartest docs I eve4r met are neurologists, but that doesn't change my observation that most neurologists I've met, in my experience, show an incomplete grasp of the nuances involved in image interpretation.

I have seen several neurologists -- in the printed media and on television -- put up a Representative CT of the brain of a normal 25 year old female and contrast this with Terri Schiavo's CT. This is a totally spurious comparison. No one is disputing that Terri Schiavo does not have the CT of a 25 year old female.

What I'm saying is that Terri Schiavo's CT could be the brain of an eighty or ninety year old person who is not in a vegetative state. THOSE are the CT scans we should be showing next to Schiavo's, because in THAT case you would see similar atrophy and a brain much closer to Schiavo's.

Who Wants To Be A Millionaire?

To prove my point I am offering $100,000 on a $25,000 wager for ANY neurologist (and $125,000 for any neurologist/bioethicist) involved in Terri Schiavo's case--including all the neurologists reviewed on television and in the newspapers who can accurately single out PVS patients from functioning patients with better than 60% accuracy on CT scans.

I will provide 100 single cuts from 100 different patient's brain CT's. All the neurologist has to do is say which ones represent patients with PVS and which do not.

If the neurologist can be right 6 out of 10 times he wins the $100,000.

Much has been made over the issue of Terri Schiavo’s swallowing. It is because Schiavo cannot swallow that a feeding tube was inserted directly into her stomach.. It is this feeding tube that has been the object of gargantuan legal, moral and ethical struggles.

But what is swallowing and why should it carry such import?

There are three stages of swallowing: the oral, chewing phase; the pharyngeal reflex phase wherein the food is propelled over the vocal cords and into the esophagus; and, the esophageal stage, during which food travels to the stomach.

The fight over Terri Schiavo involves only one of these three stages and that is the pharyngeal stage.

During the pharyngeal stage of swallowing, the body senses there is food in the back of the throat. This “sensation,” initiates a reflex:an involuntary muscle contraction akin to a knee jerk.

In one rapid sequence the body shutters the nearby opening to the lungs (the trachea) and shunts the food to the esophagus. The reflex is over and the food travels down the esophagus to the stomach.

Swallowing, Breathing, Beating – Not The Same Family

In this way swallowing is entirely different from breathing and heart beating. Breathing and heart beating go on constantly, without stop. Although they too have reflex properties associated with certain of their functions, the motors for breathing and heart beating are in an ever-on position, the alteration of which would mean rapid demise of the organism.

This is not the case with swallowing which, being a reflex, is only used sporadically, during feeding. This is the crux of the case that has been ignored – no abused – by the ethicists and lawyers involved with the Terri Schiavo case.

Most reflex circuits are local, and wired differently from other motor functions. When there is pizza in the back of the mouth the body cannot wait for the cerebral cortex to give permission to swallow. Instead, the rapid swallowing reflex obeys a different, shorter circuit, (much the same as the knee jerk) involving a brief pathway to the nearby brainstem. Studies show that the cerebral cortex is important only in the voluntary initiation of swallowing.

So Why Are We So Focused on Terri’s Cerebral Cortex?

Neurologists, ethicists and hospice specialists are parading across the news each day affirming that Terri Schiavo has so little cerebral cortex that she cannot possibly think, feel or act volitionally. Yet the debate over ending her life is centered NOT on any essentially cortical activity – the debate is over a reflex that occurs on a different neurological level.

What the courts have decided is that because Terri Schiavo has lost the ability to initiate and reproduce this local, noncortical neurological reflex, her fate rests in the hands of Michael Schiavo.

The obtrusive error that has been made here, by the ethicists and the courts, is in centering this case on that reflex.

There can be no doubt that if Terri Schiavo maintained the brainstem swallowing reflex -- everything else being equal -- there would be no court case, and no national hand-wringing. Ms. Schiavo would be left alone to live out her life under the care of her parents.

But we should no more be basing the life and death of Terri Schiavo on this reflex than we should on a knee jerk.

Can’t Pee? Stay Away From Florida’s Courts

What the courts have done is to pick one reflexive neural pathway and decide that this is the critical and key determinant of life and death.

The mistake that has been made – the knot that is being undone – is in centering this legal and ethical decision around the swallowing reflex. Because, the case can now be made that other similar reflexes may similarly be exploited.

Namely, I am thinking of micturation. Urination. Peeing.

Urinating is more akin to swallowing than swallowing is to breathing or heart beating. The urinary bladder fills with liquid and thus stimulates neuroreceptors in the bladder wall that in turn leads to the urination reflex.

Another Tube, Another Problem?

More frequently than swallowing, urinating is a reflexive process that is frequently dysfunctional. For many reasons there are people who cannot adequately perform this reflex and who therefore need the assistance of a tube. In this case it is not a feeding tube allowing ingress to the body; rather, it is a urinary catheter which allows egress.

Tens of thousands of Americans live today with catheters in their urinary bladders. These catheters may be transurethral (through the penis or female urethra) or percutaneous (stuck through the body wall directly into the bladder).

What would happen if one were to remove the urinary catheter from those who have them? They would die. Slowly, urine would accumulate, the kidneys would become engorged via backflow, and nitrogenous wastes would build up in the bloodstream leading to coma and death.

In this sense, there is no difference between a feeding tube and a urinary catheter. So why are we not talking about removing Terri Schiavo’s urinary catheter? Why are we focused on the feeding tube?

That the courts should decide that the primitive local reflexive action of swallowing is the deciding physiological factor between life and death makes no sense physiologically, teleologically or morally.

There is nothing inherently nutritive about swallowing. Neither does the absence of this reflex necessitate death, as would one see were respiration or circulation suddenly be cut off.

The Living Will of the Future?

The bogus argument over Terri Schiavo’s “living will” or desire “not to live like this” has devolved into the presence or absence of this swallowing reflex. Therefore, all living wills in the future will, by necessity, need to be broken down into checklists of neurological items constituting an inventory of both voluntary and reflexive neurological activities that we are either willing, or not willing, to live with.

Would you live without a knee-jerk reflex? Without a sneeze? Without the exhaustive reflexes of micturation and defecation? Which will you choose?

Deeply comatose. No evidence of
acute process in CT scan. Evidence of myoclonic seizures. Rule out acute
myocardiac infarction, seizures as cause. Neck is somewhat stiff as is all of
the muscles of the body. No jugular venous distension. WBC 26,300, drug screen
negative

If you look carefully at this time line you will see that Terri had "NORMAL" CT's of the brain on 2/25 and 2/27.

STOP THE PRESSES

There is categorically and absolutely NO WAY Terri could have suffered MASSIVE ANOXIC INJURY TO THE BRAIN ON 2/25 AND HAVE NORMAL CT SCAN ON 2/27

NO WAY

Brain edema begins to occur about 20 minutes after infarction and by 24 hours her brain (if she HAD suffered a massive anoxic event) would have been MASSIVELY SWOLLEN -- something that could NEVER be missed and NEVER called normal.

NEVER.

If Terri's brain CT was NORMAL 2 days after she entered the hospital than there is NO POSSIBLE WAY she suffered a massive infarction or global ischemia on 2/25.

THIS IS ALL WRONG

Now look at 3/30. Suddenly she develops NONCOMMUNICATING HYDROCEPHALUS.

WHAT?

Did anyone ask HOW? How did she develop noncommunicating hydrocephalus suddenly on 3/30/90 with 2 normal CT scans on 2/235 and 2/27??

CONCLUSIONS?

1. IF this is an accurate report (normal CT brain on 2/27 -- injury on 2/25) then TERRI DID NOT suffer an event of massive ischemia on 2/25. tHERE IS NO RADIOLOGIST OR NEUROLOGIST OR NEUROSURGEON IN THE WORLD THAT WOULD DISPUTE THIS. it is impossible. tHE ct ON 2/27 WOULD HAVE BEEN grossly ABNORMAL.

2. IF TERRI DID NOT SUFFER ANOXIC DAMAGE ON 2/25 THEN THE REASON FOR HER BRAIN ATROPHY WAS CAUSED BY SOMETHING THAT OCCURRED after 2/25 namely in the hospital during February or march of 1990.

3. How does one develop NONCOMMUNICATING HYDROCEPHALUS in ONE MONTH? By a blood clot obstructing the CSF outflow from the brain at the Foramen of Magendie.

4. How does one get #3.

BY BEING HIT ON THE HEAD AND SUFFERING INTRACRANIAL HEMORRHAGE.

So Terri WAS HIT ON THE HEAD OR DROPPED ON HER HEAD DURING LATER FEBRUARY OR EARLY MARCH WHILE IN THAT HOSPITAL.

THE FEEDING TUBE MUST BE REINSERTED IN ORDER TO GET A NEW CT OF THE BRAIN

I have offered the following proposition to Terri Schiavo's legal team today:

The single CT image I was able to access at the U of
Miami's web sight raises the following ESSENTIAL questions/issues:

Issue: There is something in Terri's right ventricle
(the image is reversed). I know she had thalamic implants, but on this one
slice the "thing" in Terri's ventricle is not projected to the
thalamus, it is projected within the ventricle. She needs a follow-up scan
to see what this is and where it is

Issue: If the "thing" in Terri's ventricle is
a "shunt tip" -- who put it there and why is it there and was it removed?
If she was shunted to relieve hydrocephalus then she must have follow-up exams
and someone needs to postulate the most common mechanisms for hydrocephalus
(which, I believe, is blood in the cranial vault)

Issue: Given this ONE image, NO ONE can exclude the
possibility that Terri, at that time, had hydrocephalus.

I see all
the classic signs:

1. Enlarged ventricles

2.
Rounded, bulbous front and back ventricle horns 3.
"Pressure" effect on the occipital lobes of the brain (which, by
the way, do not -- on this image -- demonstrate the atrophy seen
everywhere else)

*People with untreated hydrocephalus OFTEN SHOW IMPROVED
MENTATION WHEN THE OBSTRUCTION IS RELIEVED.*

So, if the other images bear out my impression from this
one slice, then Terri MUST have a follow up CT or MRI or BOTH and if she is
hydrocephalic she needs to be shunted, because there are possible
positive therapeutic implications that no one can deny.

What if The State and Terri's Tube-Remover Ignore This ?

If she is NOT shunted it is my contention that there is no physician ANYWHERE who could say, in the future, definitively, that Terri did not have hydrocephalus at the time of that particular CT slice.

What does this mean? Everything.

As I said, nonshunted hydrocephalics can experience improved mental functioning after shunting. I am not saying this would be the case with Terri (because of how long this has gone on); however, what I AM saying is that if they DON'T do a repeat CT scan NOW BEFORE TERRI DIES, the evidence will be on that scan forever. They will never be able to say it wasn't so.

Do they want to face their own carnivorous legal system when the dogs of war are let loose after Terri dies? I WILL BE THE FIRST TO TESTIFY. I will say that one cannot exclude hydrocephalus on that image. ONE MUST REPEAT THE SCAN. Basically, given THAT image the onus is on them to prove she is NOT
hydrocephalic -- meaning she needs a repeat CT, and to do that they
need to reinsert the feeding tube.

If they proceed as is, with that image out there on the internet, the
person(s) who pulled that tube had better be aware that they are in
jeopardy of actuating a death when there were standard medical
procedural methods that had yet to be deployed.Here's what they can look forward to at the trial:

Dr. Boyle: ONE MUST REPEAT THE CT SCAN

Tube-Puller: Why?

Dr. Boyle: BECAUSE SHE MAY HAVE HYDROCEPHALUS.

Tube-Puller: O come on, that's ridiculous.

Dr. Boyle: MAYBE. BUT SHE MAY HAVE HYROCEPHALUS.

Tube-Puller: O come on. So what?

Dr. Boyle: HYDROCEPHALICS CAN IMPROVE WITH SHUNTING.

Tube-Puller: But she was brain dead. You're insane

Dr. Boyle: MAYBE. JUST REPEAT THE CT SCAN AND PROVE ME CRAZY.

Tube-Puller: we can't do that

Dr. Boyle: WHY?

Tube-Puller: She's dead. I pulled out her feeding tube.

Dr. Boyle: DEAD? HOW DID SHE DIE?

Tube-Puller: Dehydration. Starvation.

Dr. Boyle: I'M SORRY FOR HER. I PITY YOU.

Tube-Puller: Why?

<>

Dr. Boyle: I CANNOT CHANGE WHAT IS ON THAT FILM. SHE MAY HAVE HAD HYDROCEPHALUS. IF SHE DID, SHE MAY HAVE EXPERIENCED IMPROVEMENT WITH SHUNTING.

Tube-Puller: That's a lot of maybes.

Dr. Boyle: THAT'S ALL TERRI HAD. YOU SHOULD NOT HAVE PULLED THAT TUBE. YOU ARE CULPABLE. I'M AFRAID IT'S MURDER.

Tube-Puller: that's idiotic. I only did what I was ordered by the courts to do.

Good day to all and thank you for coming to visit the 131st Carnival of the Vanities, begun by the gifted and talented progenitor Bigwig at Siflay Hraka.

If you see smoke emanating from this blog site it is because of quite a controversy that has been roiling CodeBlueBlog this week, and I apologize if this gets in your way...but the show must go on!

The Top Story -- And Breaking News:

Looking for the next blogger to break out into national attention with cutting edge material BEFORE the MSM? Eric McErlain of Off Wing Opinion is my bet. The rubric is sports, but the information is erudite and insightful... and I think he just landed a blue marlin:

In Title IX Earthquake, Eric blows the doors off a story not yet read or reported in MSM --It's about a change in enforcement of the controversial Title IX rule. Go read it.

TOP STORY 2

The Neolibertarian Network Has Arrived

I don't know about YOU, but I've always wanted to be a Libertarian except that I always felt that Libertarians were sort of like Liberals in that they had lofty and admirable notions that were largely inapplicable to the exigencies of day-to-day life. The Neolibertarian Movement has settled that issue, and I'M SIGNING UP!

What's a neolibertarian? I don't want to spoil it for you but it just may be a more workable form of a political philosophy that is, at its roots, highly attractive. The QandO Blog is the place for you to click it out.

A Blog Of Note and To Be Noted:

The Glittering Eye should get YOUR eye every day. It's author lists interesting items throughout the Internet on a daily (or more) basis which serves as a jumping point for like-minded readers.

And you MUST check out his coverage of the Iditarod -- because it is SO cool.

My Med Buds

Since this is MY HOUSE, I'm going to use the rules a little and introduce you to my family and friends in the medical blogosphere. We are really good, and you can get yourself clean here. It's information you need, and there is a lot of it by experienced physicians, nurses, techs, students, and more.

Nick at Blogborygmi gets poetic, no Whitmanesque while expatiating about the new RedTacton technology -- devices that purportedly will transmit data over people's natural electric fields. Dare I say ecstatic?

New med blogs crop up every week. I have trouble keeping up nowadays, mainly because I feel like I'm juggling twelve Faberge Eggs every day...but, seriously, there have been a couple of great new med blogs you just GOT to visit. One of these is Dr. Tony, and his recent humerus post about an "enterprising" platelet is not only funny, it's instructive.

DO NOT miss Effect Measure, an IMPORTANT medical blog with cutting-edge posts about bird flu (you MUST follow this story).

Respectful Insolence (a.k.a. "Orac Knows") is a physic an with consistently worthwhile posts, who recently wrote a four part series about the deadly power of denial, concluding with the denial that occurs in the treating physician. Read Orac.

I check in with Kevin, M.D. every day for his slant on the news, and to RangelMD for his thorough, intelligent blogging. Then there are the Senators and Voices of Reason (helping to balance out CodeBlueBlog): DB's Medical Rants and Medpundit.

I would be remiss if I didn't mention The Mad House Madman, for whom we all have love. There's a new being in his life, so his blogging is currently...colicky.

CodeBlueBlog's Question of the Week: What is Life?

What constitutes life is a never ending argument; but, in the witness of death, we all hang our heads in agreement.

Only The Good...

Amba adds a third dimension to the orthogonal views of my previous apothegm at AmbivaBlog. It's foreign, and poignant. Read the author's bio...we have ALL KINDS of talented people out here in this ethereal blogosphere!

Terri Schiavo

My Carnival would not have been complete without Eric Scheie of Classical Values sending me a post. Thanks, Eric. BOOK MARK HIS SITE. It is always good, and contains TONS of info. I once asked Eric where he found the time to think and write into his blog as much as he does (as I labor past 2 AM Tuesday night!)...and he emailed me: "My loss is your gain. lol"

He's right! This is what the blogosphere is all about. FREE stuff in great proportions. Read what Eric has to say about the Terri Schiavo case in Politicized to Death.

I just recently found The Smarter Cop, and IT'S GOOD. Read this exquisite analogy that ties itself to Terri Schiavo. Well done.

I respect and admire P.Z. Myers -- of Pharyngula -- and any time he has something to say, I listen and I take him seriously. He's good. He's passionate. His blog rocks. He references H.P. Lovecraft -- one of my first big fiction obsessions. P.Z. steps back in the Schiavo case to express what I take as his exasperation. A Lovecraftian auditory phenomenon expresses all that.

BlueStateRed cogently addresses what many are thinking and saying: that despite the exigencies of the Schiavo case, the intervening of Congress and the President are in many ways baffling, and perhaps, even a poor gambit. Steven M. Couch places blames on all parties in this NEAT little piece that responds to the insufferable Peggy Noonan. Bookmark this blog.

I stopped videotaping obstetrical ultrasounds for parents over ten years ago when I realized that I was setting myself up for a fall (and I saw it happen, subsequently to other Docs) because I like to try to think like a Torter (*snap* *snap*) in order to avoid their snapping beaks. PUNDITGUY sees this phenomenon now in videotaping of births, and he is RIGHT ON with his analysis of the implications. A must read is Stop The Tape!

I-P is really onto something here. I'm not trying to be funny, or sardonic, or clever. Is there a social tide turning or have we uncovered another long, deeply buried reality. I would keep working on this one, Mike.

One would think the nation that claims to be bringing freedom and democracy to the world would believe in moral accountability. What am I thinking! This is the same country that has committed genocide, germ warfare, mass murder and slavery.

Rights Talk

Mary Ann Glendon has nothing on The Smallest Minority. You really should visit and read the exegetical What is a "Right" written by the soul-searching inhabitant of this blog, It's solid thinking material.

MARK HELPRIN DIGRESSIONS: Reading the above COFFEE link, I am reminded of Mark Helprin's novel, Memoir from Antproof Case, about a man who desperately despises caffeine. And if you never read A Soldier of The Great War, then you missed one of the greatest American novels of all time (no THE GREATEST AMERICAN NOVEL -- it's MY day, right?).

By coincidence, Planting Hands sent me a submission about one subject and I noticed a MARK HELPERIN link at the top of the page. So I'm using editorial insouciance and gleeful coincidence to excuse my changing the submitted link to the Helperin link because it is in regards to Winter's Tale (think Shakespeare) which was also one of the best books I ever read.

So excuse me robintilling for this switch but know that I think you an intelligent being of the highest magnitude. We'll have to keep an eye on this blog.

Non quantifiable phenomena of cognitive and post-purchase dissonance are used to explain conservatives reactions to the recent NY Times revelation that major weapons installations were looted after the fall of Baghdad in The Opposite of Buyer's Remorse at Threading the Needle.

Journalism majors at Harvard may soon have prerequisites in terrorism. The Stone City lays the groundwork for the doppelganger scenario in Citizens of the World.

Are the psychological foci of ideology and religiosity so close together that they can substitute for each other? Or are there unconscious mechanisms hard-wired in the human brain that allows them to influence each other? At Shrink Wrapped a psychiatrist and psychoanalyst uses his erudition and skills to elucidate a novel theory regarding the origin of liberal ideations in: Political Deification.

There are oceans of ideas in which my ship has never sailed. And never will. But for those of you who indulge in precisely defining and developing your sexuality and sexual relationships, the blogosphere can be a canal to another sea. And so you might enjoy, even understand An Alpha Female Bares Her Throat Only To Her Mate, and many of the other regular posts at the FCC unregulated site Taken In Hand.

Blog d'Ellison is good. This is also how the whole blogger phenomenon started, with clever, intelligent people saying funny and insightful things about their everyday lives. Read Fast Times. And is that REALLY your DAUGHTER?!

The blogger phenomenon also started with blogs like this one written by "melinama" from North Carolina. Henry Doesn't Like Snakes is about experiences, but they are widely applicable, important, and instructional, and this is written well, too. I really like finding these kinds of blogs.

And speaking of Liz, she didn't send me anything, but I'm going to send you over to her site, I Speak of Dreams, because it is intelligent, informative, well-oriented and represents a lot of good and hard work. You will really enjoy bookmarking the site -- it has the CodeBlueBlog seal of approval.

Good stuff about our FAVORITE sports event: MARCH MADNESS. The key monk weighs in with NCAA Commentary. I'm bookmarking this one.

Polly Ticks Eko Nomicks and Bizniss

The Silence of The Dems: Why didn't the Democrats make an issue of the Enron and Worldcom scandals during the last election? Brian Goettl at The Conservative Edge has an insightful take on the recent conviction of Bernie Ebbers.

Ashish's Niti, asks us: If corporations create jobs, pay taxes and provide profits, do they "owe" anything to their local community? Are they obligated to "give back?" We Don't Owe Nothin' provides a link to a CEO with an answer.

The Conservative Cat, who's cleverly generated submission forms have peppered my mailbox this week, has also created a JavaScript "freedom counter" that is keeping track of the dollars spent on creating and maintaining freedom in the Middle East. It's for observers from Mars. See

At DSSHubris one of the contributors talks about the incompatibility between the often articulated phrases: "I support the troops"... but.. "not the war.

How do we all attract more readership from the general public? Blog Business World addresses and defines the issue and offers suggestions in a post that deserves linking, pasting and READING.

Sophistpundit (is that a portmanteau word that is simultaneously an oxymoron? ...Sorry...) wants to put things in perspective on the second anniversary of the Iraqi invasion. He posts a letter from someone whose cousin was horribly wounded.

It is my opinion that the most likely reason for these bone scan findings in March of 1991 is that someone either was physically abusing Terri or they dropped/mishandled her severely.

A reader asked me to comment on Terri Schiavo's bone scan report.

Here are my initial thoughts:

It is perilous to try and interpret just the bone scan REPORT. I need to see the scan itself and the correlative X-rays.

However, that being said, several things are unusual.

First, the DATE on this bone scan is March 1991. Terri's cardiopulmonary arrest -- as far as I can tell -- was in February 1990; therefore, the abnormalities that are described occured AFTER Terri's February 1990 arrest, probably in the weeks or month(s) just prior to the bone scan, unless she had a second arrest at some point -- and I do not have that history. Certainly there was trauma. As I understand it, the issue is how the trauma occurred.

Trauma from CPR generally involves the anterior aspects of the ribs where they join the sternum. This is usually due to vigorous compression during CPR. Any other proposed trauma during CPR would need to be documented by the notes or by eye witnesses as to the mechanism (e.g.: did she fall off the stretcher?).

The bone scan report of TS describes an injury NOT to the anterior ribs, but, to a different part of the ribs-- posteriorly -- namely at the juncture of the ribs and vertebrae (the costovertebral juncture, or CVJ). In addition, although the report mentions several rib fractures, it does not specify if they were all CVJ located or in different/various locations. This is important. Finally, I do not see a report of correlative x-rays for the ribs, which would be helpful to determine the TIMING of the injury (fractures look very different depending on WHEN they occurred).

The compression fracture of L-1 is interesting. This is certainly NOT a typical injury that occurs during CPR as it generally involves an AXIAL load (i.e. on the top of the head; or from the top DOWN); a caveat here: if TS was anorectic for a prolonged period or on certain medications she could have been osteoporotic, in which case some might claim that a mild compression fracture of L-1 would not be so unusual-- however this is only true in ambulatory people, which Terri was not.

The uptake over Terri's distal right femur is the most peculiar element in this report. This is an unusual finding in ANY situation and I would have to see the scan and films to be sure of what it means; however, if there is PERIOSTEAL ELEVATION then one would have to posit (as did the person who interpreted Terri's bone scan) the possibility of bleeding underneath the thin covering of the bone (the periosteum) which is a finding that correlates highly with trauma, specifically, abuse.

It would be difficult to propose a mechanism that caused this type of problem unless a specific witness arises to declare he or she remembers a specific event that would have caused this UNUSUAL finding.

I would want to know if Terri had a BLEEDING problem at any time, because that might explain this finding.

Certainly IN A CHILD (which Schiavo, obviously was not), the combination of posterior rib fractures, vertebral compression fractures, and distal femoral periosteal elevation is ABSOLUTELY POSITIVELY DIAGNOSTIC for child abuse and any radiologist who missed this diagnosis would be subject to disciplinary action from his peers and state licensing board. SEE: http://radiographics.rsnajnls.org/cgi/content/full/23/4/811

It is my opinion that the most likely reason for these bone scan findings in March of 1991 is that someone either was physically abusing Terri or they dropped/mishandled her severely.

The x-rays might make all of this clearer if we can obtain them.

n.b.

Teri's fractures could be of the "insufficiency" type (caused by prolonged immobilization/dietary irregularities) and some might posit this explanation; however, in a nonambulatory bedridden patient under careful supervision, I find this untenable, especially given their distribution which are so typical for ABUSE.

Thanks to reader "primer" I've been directed to the University of Miami Ethics program website where they posted this image from a CT scan of Terri Schiavo's brain in 1996. The sentence attached to the link for this scan on the site says:

Since 1990, Theresa has lived in nursing homes with constant care. She is fed and hydrated by tubes. The staff changes her diapers regularly. She has had numerous health problems, but none have been life threatening.

Over the span of this last decade, Theresa's brain has deteriorated because of the lack of oxygen it suffered at the time of the heart attack. By mid 1996, the CAT scans of her brain showed a severely abnormal structure. At this point, much of her cerebral cortex is simply gone and has been replaced by cerebral spinal fluid. Medicine cannot cure this condition. Unless an act of God, a true miracle, were to recreate her brain, Theresa will always remain in an unconscious, reflexive state, totally dependent upon others to feed her and care for her most private needs.

First, I contest the theory that Terri's brain actively continues to degenerate as implied by the above statement. How could they gage serial brain degeneration without serial follow-up? And by what mechanism would her brain CONTINUE to atrophy? Second, Terri's cerebral cortex has not been replaced by fluid. That is inaccurate. The cortex is thinned and the sulci are enlarged. There is a difference.

Third, and most importantly, given the amount of atrophy on this image I disagree with the court's inadequately considered conclusion.

First of all, the University of Miami's appellation for this scan is inaccurate. "Cortical regions" are not and can not be filled with spinal fluid. The sulci (spaces between cortical ribbons) are enlarged secondary to cortical atrophy and these sulci are filled with cerbrospinal fluid.

The most alarming thing about this image, however, is that there certainly is cortex left. Granted, it is severely thinned, especially for Terri's age, but I would be nonplussed if you told me that this was a 75 year old female who was somewhat senile but fully functional, and I defy a radiologist anywhere to contest that.

I HAVE SEEN MANY WALKING, TALKING, FAIRLY COHERENT PEOPLE WITH WORSE CEREBRAL/CORTICAL ATROPHY. THEREFORE, THIS IS IN NO WAY PRIMA FACIE EVIDENCE THAT TERRI SCHIAVO'S MENTAL ABILITIES OR/OR CAPABILITIES ARE COMPLETELY ERADICATED. I CANNOT BELIEVE SUCH TESTIMONY HAS BEEN GIVEN ON THE BASIS OF THIS SCAN.

The worrisome, no alarming thing, for me, was that I heard a bioethicist and several important figures on the major media describe Terri's brain as MUCH WORSE. One "expert" said that she had a "bag of water" in her head. Several experts described her as a "brain stem preparation"

These statements are wholly inaccurate. This is an atrophied brain, yes, but there is cortex remaining, and where there's cortex (?life) there's hope.

If you starve this woman to death it would be, in my professional and experienced medical opinion, the equivalent of starving to death a 75-85 year old person. I would take that to the witness stand.

All That Glitters is a SHUNT

Next mystery: Why is there a shunt in Terri's ventricle? This CT image is "flipped" (i.e. the CT scan is mirror-image backwards which is just an inconsequential error made when scanning the image into the computer), so the right side is LEFT and vice versa. However, everyone can see, easily, the ovoid white object sitting in the front of the big black butterfly in the center of Terri's brain, correct?

That shining object is the tip of a shunt. A shunt is a tube inserted into the brain to reduce pressure caused by build-up of cerebrospinal fluid (CSF) in the brain. That big black butterfly in the middle of Terri's brain is her ventricular system, which holds the CSF and in Terri's case, it is enlarged (dilated).

Now...why was Terri being shunted in 1996? First, if Terri's brain damage was due to oxygen deprivation, her enlarged ventricles would be by a passive mechanism -- which is not amenable to shunting -- not by obstruction of the egress of CSF. To me, the presence of a shunt indicates obstruction to the flow of CSF that needs to be circumvented. Obstruction to flow is hard to postulate given the mechanism of Terri's brain injury (oxygen deprivation).

It would NOT be hard to postulate, however, if she had BLOOD in her head at some point in the past. So did she? Was there a history of trauma? I would like to see the BONE SCAN taken of Terri that purportedly showed evidence of traumatic type osseous uptake!

It is quite unusual to see high-pressure hydrocephalus when the mechanism of brain injury was INFARCTION; and, more so six years after the event.

So

IS THIS REALLY TERRI'S CT?

IF it is then her atrophy is SEVERE, BUT not as bad as has been implicated by the press and the courts

IF it is then why did she have hydrocephalus six years after her non traumatic infarction

IF it is... why was she shunted...AND IS SHE STILL shunted? IF not, why was the shunt removed?

IF it is, why does the Second District Court NOT mention Terri's hydrocephalus in it's dissertation on Terri's woeful cerebral condition??

IF Terri DOES have hydrocephalus from ventricle blockage, was there trauma that caused bleeding that lead to hydrocephalus on the basis of a blood clot obstructing ventricular outflow?

IF so, what was that trauma?

IF Terri had hydrocephalus in 1996, she may still have hydrocephalus now; some patients with hydrocephalus respond to shunting with increased mental functioning!

IF THIS IS NOT TERRI'S CT THEN WHERE IS HER CT?

Based on this evidence Terri Schiavo should have a CT scan repeated. She should also have an MRI and a PET scan to gage the severity of her brain dysfunction.

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Thanks to Silflay Hraka for starting the Carnival , and thanks to those who are about to send me their best work for the weekly showcase here on 3/23/05.

I've written before about the case of Terri Schiavo. In brief, my position is that I do not believe that physicians should actuate death. Society may make that choice, but I will not carry out the sentence. I didn't spend ten years in training to starve people to death.

Although my take on this case has not been politically oriented, it seems that the lines have been drawn between Democrats and Republicans. As stated by NPR this A.M.: Democrats are coming down hard on the side of pulling Terri Schiavo's feeding tube.

Why are the Democrats so hell bent on killing Terri Schiavo? This is quite baffling. Democrats, who demand life be preserved for

homicidal maniacs who have low IQ's

homicidal maniacs who are 17 years old

sea turtle eggs

How can one simultaneously insist on preserving turtle eggs and not preserving a living woman?

Worse, the arguments I consistently hear from those who want Terri dead don't make sense. Their positions are rife with illogic, such as:

Terri is not Really Alive

I have actually heard bioethicists (on NPR -- from the University of Miami Medical School) talk disparagingly about those who insist that Terri Schiavo is alive. Whaa?? That's right. This BIOETHICIST'S claim is that because our personalities and powers of thinking are located in the cerebral cortex and Terri's cortex is destroyed (Query to bioethicist: All of her cortex? Have YOU seen the MRI's?? Is there a specific volume of cerebral cortex below which you make this asseveration?) Terri is therefore actually NOT ALIVE.

Well then I ask you, is she dead?

That becomes the salient question, because it seems that we are having a debate over when we are ALIVE, but certainly we all know when we are DEAD, don't we?

Is there anyone who will stand up and announce to the world that Terri Schiavo is, by definition, DEAD??

Terri Won't Feel Pain if We Pull the Tube

The argument is that because Terri is essentially decorticate, she will not feel the pain of starvation and dehydration. But If Terri cannot perceive pain, then she is not currently suffering and faces no future of suffering, so there is no humanitarian reason to kill her ( if such a thing exists).

Terri Can't Feed Herself

The argument that Terri cannot feed herself is patently absurd and dangerous. Alzheimer patients, amputees, infants, and those with severe mental impairment are unable to feed themselves. Would we kill them?

Terri did not Want to Live Like This

Contrary to popular belief, Terri did not make her wishes clear. Her husband claims that after seeing the story of Karen Quinlan on television Terri expressed the idea that she would not want a similar fate. Of course, Terri's fate is not the same as Karen Quinlan's, and Terri's husband's motives have been called into question.

If Terri had seen a show on the potentials for stem cell research leading to neuro-regeneration technology, and had expressed approval, would her fate be different?

The Stance on Stem Cell Research

During the last presidential campaign I heard Democrats pounding away about the imminent miracles of stem cell research. Democrats were praising the astounding potential of this technology, including the report of neuroregeneration in frogs.

So if in five years cerebral neuroregeneration is a reality, can we prosecute Terri's tube-pullers for murder?

What is the Motive of Democrats?

So why do Democrats want Terri dead? They insist she is in no pain and has neither the mental capacity to feel or understand pain or emotional grief or discomfort.

Therefore, by the Democrat's own argument Terri has no comprehension about what is happening, or whether or not her wishes are being fulfilled. Terri will experience nothing adverse, physically or mentally, as a result of letting her live and letting her loving parents take care of her as they wish.

Who with a daughter would not take the same stance as Terri's parents given the above? Who of you would not care for your daughter in similar circumstances? Who of you would pull that tube out of your daughter?

The Line of Life

The Democrats, who cry about rights for the eggs of animals, disparage all of those who speak about the right to life for a human. I am not one who can be characterized as a "right-to-lifer" but I have no problem in saying that without THAT right, all other rights are extinguishable and irrelevant.

It is my opinion that the reason the Schiavo case has garnered so much attention is because it is about drawing lines. We have to draw lines somewhere, and Terri Schiavo is the line of life here. It would be a grievous error for the State to insist that we kill her, because, clearly we must ask: "Who is next and under what newly contrived circumstance?"

Terri Schiavo is alive, in no discomfort, well taken care of, and did not clearly express the desire to die, as her opponents insist. For the State to be mandating that we pull out people's feeding tubes should be a frightening event for everyone who ever gave a dollar to the ACLU, and I cannot understand why that organization is quiet in the one situation where their principals are so in jeopardy.

ADDENDUM:

I should have known better. The ACLU HAS weighed in on this case AGAINST the life of Terri Schiavo. What else would you expect? They did not come out for her right to LIVE...they came out for her right to DIE.

Let me see...how does it go? DEATH, LIBERTY AND THE PURSUIT OF HAPPINESS??